AMERICA’S
HISPANIC
COMMUNITY
Bienestar
Improving health outcomes
through engagement with
health care professionals
872541 10/13 Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company or their affiliates.
Part 1: The context
A dramatic demographic shift is taking place across the United States. Hispanics — the largest
“minority” in the United States — are now part of the American mainstream. U.S. census data indicates
that about one in six Americans is Hispanic — roughly 50 million people — more than double the
number in 1990, and more than the populations of Canada, Denmark, Iceland, and Norway combined.
As a group, Hispanics account for 56 percent of all U.S. population growth. By 2025, Hispanics are
expected to make up a quarter of the population.
Hispanics are at the forefront of “the shift” toward America’s
“new growth majority”
The graphic below puts the recent growth of the U.S. Hispanic
population into perspective as compared to other minority
groups:
188
4,524
PER
137,684
PER DAY
HOUR
PER MONTH
GROWTH OF
U.S. HISPANIC
POPULATION
451,870
1,652,210
PER YEAR
490,266
PER YEAR
PER YEAR
African American and
Black non-Hispanic
Asian and
Pacific Islander
Hispanic Americans
U.S. MINORITY POPULATION GROWTH 2000-2012
FAMILY
IRITUALITY
SP
CULTURAL
APPROACH TO
HEALTH CARE
2
Bienestar
CO
MMUNITY
AMERICA’S HISPANIC COMMUNITY
HEALTH
Additional considerations:
• One in four babies born each year in the United States is
Hispanic.
• If Hispanics in the United States were a country, they would
be the second-largest Spanish-speaking country in the
world and, with $1.5 trillion in buying power, the 15th largest
consumer economy in the world.
• As consumers, Hispanics outspend non-Hispanics per capita
on electronics, movies, clothing, health and beauty products,
videos, CDs, and groceries.
These statistics underscore the critical importance of engaging
Hispanic Americans. This is a must for growth-oriented firms in
all industries, but especially in health care, where understanding
Hispanic cultural characteristics and preferences is a prerequisite
to better health outcomes.
Cigna is taking a lead role in this effort. As an organization
striving to be more customer-centric, Cigna is implementing
the strategic and organizational steps necessary to identify
and address the health care needs of Hispanic Americans. For
example, the company is refining its communications and
educational resources to relate more effectively to Hispanics
as health service consumers and as individuals. Cigna also is
partnering with health advocacy and professional groups to
help resolve health issues and concerns specific to the Hispanic
community.
Bienestar: The Hispanic concept of a state of deep well-being derived
from the interrelationship between family, community, and good health.
Helping Hispanic patients along
the road to bienestar
The U.S. Hispanic population is hardly homogeneous; it
displays as much racial and ethnic diversity as the general U.S.
population. Yet despite the wide spectrum of cultural and national
backgrounds, Hispanics tend to share an important core trait:
Their strong connections to family and community.
In fact, for Hispanics, improving and maintaining health means
attaining a sense of bienestar — a state of deep well-being derived
from the interrelationship between family, community, spirituality,
and good health. It’s a concept of holistic wellness firmly rooted in
many Hispanic cultures — a concept that has traveled north with
them to their communities in the United States.
What we know about Hispanic social
attitudes and how they relate to
health issues
In his book The Inclusion Paradox: The Obama Era and the
Transformation of Global Diversity, Andrés T. Tapia makes the
case that Hispanics tend to think in communal terms and identify
themselves as part of todo el mundo (“all the world”), essentially
meaning an extended family of relatives, friends, and fellow
members of the community. In contrast with America’s traditional
emphasis on individualism, most U.S. Hispanics are comfortable
relying on todo el mundo for help and support on matters of
personal importance, particularly health and health care.
Of special interest in cultural terms is the so-called Hispanic
Paradox – a documented finding which suggests that Hispanics
often have health outcomes and life expectancies comparable to,
or even better than, those of their non-Hispanic white
counterparts. This is especially striking because on average,
Hispanics have lower incomes and less formal education. Lower
socioeconomic status typically predicts poorer health and higher
death rates almost everywhere in the world.
One can speculate that this phenomenon is at least partly due to
the Hispanic cultural embrace of bienestar and the positive health
outcomes it represents.
At the same time, we have to be careful not to generalize too
broadly about Hispanic traits and habits. For example, Mexicans,
Cubans, and Puerto Ricans share a common language but have
separate histories and cultural backgrounds, as well as different
approaches to health care and differing susceptibilities to various
illnesses. This is in part why it’s essential to avoid making
assumptions about each group based on what we know about
Hispanic culture in general.
AMERICA’S HISPANIC COMMUNITY
3
“To help our customers with their health and well-being, we must first embrace
their individuality and understand their unique needs. Respecting the culture and
experiences of the people we serve is a springboard for innovation and equips us to
respond to seismic shifts in the marketplace.”
– David M. Cordani, President & CEO, Cigna
Health care disparities in
the Hispanic community
Despite the advantages associated with bienestar, the Hispanic
community contends with numerous health disparities compared
to the non-Hispanic white population. For example, Hispanics tend
to suffer more frequently and severely from a number of serious
health conditions:
• Hispanic women contract cervical cancer at twice the rate
of white women.
• 10 percent of Hispanics have been diagnosed with diabetes,
compared to 6.6 percent of non-Hispanic whites. They’re
also twice as likely to die of the disease.
• Hispanics experience new HIV infections at more than
twice the rate of whites.
• Puerto Ricans are twice as likely to suffer from asthma.
About one in five Puerto Rican children have the disease.
• Obesity, a national problem, disproportionately affects U.S.
Hispanic adults and children. About two in five Hispanic
children are overweight or obese.
The disparity also extends to medical care:
• Latinos undergo more diabetes-related amputations than
non-Hispanic whites, indicative of delayed interventions.
• Physicians are less likely to detect depression in Hispanics,
and Hispanics are 50 percent less likely to receive mental
health treatment or counseling.
• Hispanic children are twice as likely not to receive all their
medications. Of those taking meds, 19 percent reported
taking smaller doses or skipping them entirely.
• Hispanics who self-identify as lesbian, gay, bisexual, or
transgender are more reluctant to seek care — for HIVrelated treatment and general medical issues — and to
disclose relevant personal data once in care, based on a fear
of discrimination or social stigma.
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AMERICA’S HISPANIC COMMUNITY
Hispanics also face serious health issues because of
communication problems relating to language proficiency:
• 70 percent of Hispanic physicians speak Spanish, but only
four percent of white physicians speak Spanish.
• 33 percent of Hispanics report communication issues with
their physicians, compared to 16 percent of whites.
• Hispanic patients are four times less likely to understand
medicine labels when their physician does not speak Spanish.
• Obese Hispanic adults with limited proficiency in English
are less likely than those that are English speaking to
receive advice about the health benefits of exercise.
• Hispanic diabetes patients with limited English skills
treated by physicians who don’t speak Spanish are twice
as likely to have poor control of their blood sugar as those
whose physicians speak Spanish, even when interpreter
services were available.
• Hispanic patients who are not proficient in English are 52
percent more likely than patients proficient in English to
suffer adverse events resulting from communication errors.
“Our culture, our country, and our companies are changing. We’re starting a new
chapter in the American story, and now we have a chance to shift our thinking.”
– The Center for Hispanic Leadership
Uncovering the reasons for inferior
health care among Hispanics
Because most U.S. Hispanics belong to both a racial and a
linguistic minority, they face a particular disadvantage when it
comes to health care. We know that when people are sick, they
typically revert to their first language. As a result, they might not
fully grasp the details of verbal instructions or ask their physician
for clarification.
We also know that patients in the lower economic class,
regardless of race, are more likely than affluent patients to
receive substandard care. Because Latinos are overrepresented
in the American underclass, the issue of inferior care based on
socioeconomic status becomes especially relevant.
Numerous studies have even shown that Latinos receive inferior
care compared to whites within the same department of the same
hospital. This is a serious concern within our current health care
system. It indicates that aside from the linguistic, economic, and
cultural barriers to treatment, Hispanics may be facing biases of
medical personnel. Not surprisingly, racial minorities indicate
a lack of respect as one of their leading complaints about some
health care professionals they have interacted with in the health
care setting.
As you may be aware, any racial bias, including subtle or
unconscious, contributes to a more expensive health care
system for everyone. For example, the national epidemic of
obesity, diabetes, and cardiovascular illness is depleting our
nation’s financial resources. Racial and ethnic minorities suffer
disproportionately from these costly diseases.
As the U.S. population grows more diverse, health care costs will
spiral out of control unless we can remedy the disparities in illness
and treatment across different ethnic groups. By doing so, we not only
help marginalized groups attain parity with the white population, we
also help heal our increasingly crippled health care system.
Cigna initiatives to reduce
health care disparities
Cigna launched its Health Equity Council in 2008 with a goal
to reduce health care disparities. The Council is staffed by more
than 200 employee-volunteers who facilitate the exchange of
ideas, knowledge sharing, and identification of opportunities to
address health care disparities in culturally sensitive and medically
appropriate ways. In fact, the Council was recognized at the White
House in August 2012 by the Obama Administration for efforts to
reduce health care disparities.
A key part of the effort has been improving the cultural competency
and linguistic sensitivity of Cigna employees. More than 20,000
employees have completed cultural competency training and all
bilingual employees are tested for language proficiency.
Cigna has also collaborated with organizations such as the Robert
Wood Johnson Foundation’s Finding Answers program and
RAND Corporation to conduct health disparities research. The
Finding Answers study showed that Cigna and other health service
companies can offer resources that can be adapted as part of a
public health strategy. This strategy includes efforts to improve
patient engagement in their own health care and to help patients
of diverse backgrounds manage their health conditions so they
may obtain better health outcomes.
The serious health disparities faced by Hispanics are all the
more difficult to resolve because more than one in three Hispanic
individuals are uninsured. By comparison, only about one in eight
whites lacks health insurance. Additionally, Hispanics are only half
as likely as whites to have a regular physician or source for health
care. This gap diminishes the quality of life for too many people,
and needs to be narrowed.
AMERICA’S HISPANIC COMMUNITY
5
Part 2: The opportunity
The rapid growth of the U.S. Hispanic population presents both a challenge and an opportunity. By
engaging with Hispanic patients to gain a deeper understanding of their needs and expectations,
health care professionals will be ideally positioned to help improve their patients’ health and well-being.
The Patient Protection and Affordable
Care Act: Impacts to Hispanics
Because so many Hispanics are likely to be uninsured, they may
benefit from the Patient Protection and Affordable Care Act in a
variety of ways.
Data from the RAND Corporation suggests that because of the
health care law:
• 5.4 million Hispanics who would otherwise be uninsured will
gain coverage by 2016.
• 763,000 Hispanic young adults (ages 19 to 25) can be covered
by their parents’ health insurance.
• Over 6 million Hispanics will have access to preventive
health services with no cost-sharing (e.g., deductibles and
copayments).
• 3.9 million elderly and disabled Hispanics who receive health
coverage from Medicare will have access to an expanded list
of preventive services with no cost-sharing.
Additional highlights of the law are that it will:
• Establish state-run health insurance exchanges through
which individuals and small businesses can compare and
purchase lower-cost health insurance plans. This will begin in
2014.
• Foster the introduction of less-expensive individual and
voluntary-benefit health insurance programs, which is
an appealing prospect for the 2.3 million self-employed
Hispanics who would otherwise be unable to afford private
insurance for their small-business employees. These policies
also offer value to the millions of Hispanics who work on an
hourly or part-time basis.
The rationale behind the health care reform changes under the
Obama Administration was the recognition that our current
system fails to guarantee equal access to health care and health
insurance. Approximately 32 million uninsured people will soon
6
AMERICA’S HISPANIC COMMUNITY
be able to obtain health coverage; however, is health coverage
enough? Equal access means not only gaining entry into the
system, but finding needed services and connecting with a
health care professional who can inspire trust and communicate
effectively with their diverse population of patients.
Even in the era of the Obama Administration, approximately 20
million residents of the United States — mostly undocumented
immigrants — will not have access to health coverage. Yet the 1986
Emergency Medical Treatment and Labor Act entitles many of
them to emergency care, regardless of their ability to pay. In the
end, society bears the cost.
The Patient Protection and Affordable
Care Act: Fundamentals for health care
professionals to consider
That’s the context for the effort to improve the health of Hispanics
in America. Whether you’re a physician, nurse practitioner, or
other heath service professional, there are some key fundamentals
for you to keep in mind when it comes to treating Hispanic patients:
• Some Hispanics may have a limited understanding of the
U.S. health care system, which can be complex even when
language is not an impediment, so they may need logistical
help and support in navigating the process.
• Social and cultural factors should also be considered. For
example, Hispanics tend to view health and wellness through
a cultural prism that reflects a strong connection to family
and community. Physicians who want their Hispanic patients
to modify their behaviors and embrace a healthier lifestyle are
encouraged to engage family and friends in the effort.
• Disease management and prevention are not core concepts
for many Hispanics, Health care professionals are encouraged
to make certain that Hispanic patients understand the benefit
of regular preventive screenings. What you can do… today
The Cultural and Linguistic Work Group of the Industry
Collaboration Effort for Health — a consortium of health plans
and providers in which Cigna plays a prominent role — has made
available a useful checklist that health care professionals may use
to more effectively engage Hispanic patients. Several highlights of
the group’s recommendations are:
Build rapport with the patient.
• Recognize that patients from diverse backgrounds have
different communication needs.
• Explain the different roles of people who work in the office.
• Focus your attention on patients when addressing them.
• Learn basic words in your patient’s primary language, like
“hello” or “thank you”.
Make sure patients know what you do.
• Prepare a handout that explains office hours, how to contact
the office when it is closed, and how the primary care
physician arranges for care when referrals are required.
• Have instructions available in the common language(s)
spoken by your patients.
Keep patients’ expectations realistic.
• Keep patients informed of delays or extended waiting times.
If the wait is longer than 15 minutes, encourage the patient
to make a list of questions for the physician, review health
materials, or view waiting room videos.
Work to build patients’ trust in you.
• Be clear about your office procedures, for example, when
patients can expect a call with lab results, how follow-up
appointments are scheduled, and typical wait times.
Determine if the patient needs an interpreter for the visit.
• Document the patient’s preferred language in
the patient chart.
• Have an interpreter access plan. An interpreter with a medical
background is preferable to family or friends of the patient.
• Assess your bilingual staff for ability to serve as interpreters.
Give patients the information they need.
• Make available topic-specific health education materials in
languages that reflect your patient base.
• Offer handouts that explain the guidelines for immunization –
for adults and children – preventive screenings, and culturally
appropriate dietary recommendations for diabetes or weight loss.
Make sure patients know what to do.
• Review all follow-up procedures with the patient before he or
she leaves your office.
• Verify call back numbers, the locations for follow-up services
such as labs, radiology, or screening tests, and whether or not
a follow-up appointment is necessary.
• Develop pre-printed simple handouts of frequently-used
instructions, and translate the handouts into the common
language(s) spoken by your patient base.
Ultimately, it comes down to the basics for connecting with
Hispanics as well as the general population:
• Listen to patients and customers
• Understand what they are saying
• Help them by developing accessible solutions for achieving
their health goals
• Make it easy for them to benefit from the best possible health
services our industry can provide
Cigna is committed to a strong and lasting partnership with
health care professionals to improve the health and well-being of
Hispanic Americans.
AMERICA’S HISPANIC COMMUNITY
7
For more information
You can find helpful information and resources on Cigna’s
Cultural Competency Training and Resources page, available
on these Cigna web sites:
• Cigna.com > Health Care Professionals > Resources for Health
Care Professionals > Health and Wellness Programs > Cultural
Competency Training and Resources.
• CignaforHCP.com > Resources > Medical Resources > Doing
Business with Cigna > Cultural Competency Training
and Resources
Sources:
- NCLR 2009 Profiles of Hispanic Health: The Top Twelve Questions about Hispanics
and Health Care
- How Health Care Reform Will Benefit Hispanic Americans. Center for American Progress
- Center for Disease Control and Prevention: Diabetes, National Diabetes Fact Sheet, 2007
- NHE Fact Sheet, Centers for Medicare and Medicaid Services website
- The good and bad of health-care job growth, The Washington Post online, January 6, 2012
- Health, United States, 2010, Centers for Disease Control website
- Annual Report: U.S. Cancer Death Rates Decline, but Disparities Remain, American
Cancer Society website, June 17, 2011
- The Commonwealth Fund 2001 Health Care Quality Survey
- National Healthcare Disparities Reports 2010
- Language Barriers, Physician-Patient Language Concordance, and Glycemic Control
Among Insured Hispanics with Diabetes: The Diabetes Study of Northern California.
Journal of General Internal Medicine, 2011, Volume 26, Number 2
- The Cultural and Linguistic Work Group of the Industry Collaboration Effort for Health
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